Using the past to construct the future

Mental Health Treatment

Courtesy of Denver Public Library – Western History Museum; Prison hospital

When the Colorado Territorial Prison, eventually known as Colorado State Penitentiary, was first established in 1871, it entered a world—like the contemporary world—shaped by mental illness, a pervasive concern in historical societies as it is now.[1] The Mayo Clinic defines mental illness as a wide range of mental health conditions that affect mood, thinking and behavior, but this description looks at mental illness through a modern lens. Research on the treatment of mentally ill prisoners in the American past must acknowledge, at the outset, that there was no medical attention to the mentally ill till the mid-1900s, and even then it was scarce. Understanding of the management of mentally ill offenders in the prison system must therefore address these individuals’ conditions rather than what might now be termed “treatment.” The history of what was done to and for mentally ill prisoners is gut-wrenching—segregating mentally ill inmates from the prison community, eventually isolating them in solitary confinement, effectively worsening their conditions. And although treatment for the mentally ill has become more effective and humane in society outside prison walls, many of the improvement of the late twentieth and early twenty-first century have not been effected inside Colorado prisons.

The first reported incident of a mentally ill prisoner at Territorial was in 1876. Prison physician J. W. Daweson stated, “I would recommend … that you erect a suitable building for the proper detention and keeping of insane convicts. Asylums for the insane were not constructed with a view to the safe keeping of this class, neither is it desirable to associate the criminals with other insane persons, as the law now allows, and even may be said to require.”[2] The very first documentation referencing mental health in the Colorado Territorial Correctional Facility was thus also an appeal for funding to construct a building for the sole purpose of isolating the criminally insane. Although some prisoners were mentally unstable, Daweson’s report suggests, they found no place in insane asylums for non-offenders. The new building he proposed would keep mentally ill convicts behind bars, so insuring that they would not corrupt or injure the patients of an insane asylum. Daweson’s record was followed by an incident in 1896 about which the warden of (now) Colorado State Penitentiary stated, “six prisoners have been adjudged insane during the term…and transferred to the insane asylum in Pueblo.”[3] In the 1890’s, Territorial still did not have the resources or the capacity to manage prisoners who were mentally unstable. The prison was now required by law to send these inmates to facilities equipped and able to treat these people.

In the 1900 biennial report, Warden C. P. Hoyt stated, “We now have five prisoners who have been adjudged insane. . . .We have been unable to transfer them to the asylum for the insane on account of its crowded condition, and also from the fact that the asylum has no facilities for handling patients of this character, as they would be sure to make their escape.”[4] Nor could Territorial properly care for these prisoners. J. W. Collins, then prison physician, wrote, “This class of prisoners are now, and have always been, confined in cells and cannot be properly cared for.”[5] Hoyt then pleaded for more funding from the governor to build a new cell house for the criminally insane, as well as a new hospital and tuberculosis clinic. Mentally ill inmates were seen as a danger to themselves and others, and needed to be isolated in order to protect “the lives of the officers and prisoners.”[6]

The Colorado legislature, responding to these late nineteenth-century reports, gave the prison only half of the funds necessary to construct the proposed buildings. This money was used to build part of the hospital and tuberculosis clinic, but the mentally ill were completely forgotten. In 1906, Warden John Cleghorn insisted that the prison receive the rest of the resources to complete a project for special housing for the mentally ill: “The requirements for such a building. . .is of the utmost importance to the good health and general welfare of the institution.”[7] The legislature ignored Cleghorn’s recommendation and Colorado State Penitentiary, yet again failed to receive the money to care appropriately by early twentieth-century standards for the criminally insane.

In 1914, eight years later, prison physician Hart Goodloe recommended that mentally ill prisoners be sent to other facilities for their care: “I call your attention to the insane, and suggest that steps be taken, in conformity with the law, to remove these patients to the state insane institution, as it is better equipped to care for this class of cases.” [8] The prison continued to propose the construction of a new cell house to isolate the mentally ill inmates, but never received the funds for it. Needs of the mentally ill slipped behind more pressing issues for the prison, especially work programs and projects that made the prison profitable.

Isolating the mentally ill

In 1930, five decades after the original request for special circumstances for the mentally ill, the new cell-house for them still had not been built. Prison physician R. E. Holmes stated that, “The State of Colorado has never provided adequate care for the criminal insane.”[9] Throughout the 1930’s, Holmes begged for the Legislature to provide funding, not even for the medical treatment of the mentally ill but for their basic segregation from the rest of the prison population. As Holmes again wrote, “This is a most important problem in our hospital program, and much improvement should be worked out in this department as we are now able to give no treatment, mental or occupational, other than general cell-house care to these unfortunate inmates. I cannot urge too strongly, the development of a program for their relief.”[10] Holmes’ appeal was to no avail. In 1932, he again made essentially the same appeal, specifying the number of prisoners in the Insane Department, their sentences and the variety of mental illnesses from which they suffered. On average, there were about thirty inmates in the Insane Department at a time. These prisoners were separated from the prison proper and effectively warehoused in the basement of the hospital building. They received no medical care for their conditions. The actions taken towards the mentally ill further separated them from the prison community, on not only an emotional but also a physical level.

Holmes wished to create a psychiatric unit at the hospital to care for the mentally ill, explaining that “[t]hese unfortunates need both mental and occupational treatment which we are unable to give and I suggest that our next task be the development of a definite program for their relief.”[11] The only places that those inmates could have received any form of treatment were the overcrowded insane asylums, not the basement of a prison hospital. The prison population grew alongside the skyrocketing number of patients at mental institutions. Territorial had the capacity to hold only 700 people, but imprisoned approximately 1,000. In 1936, Holmes wrote to CSP’s Warden Roy Best, “The increased prison population at times, taxes our hospital facilities and staff to the limit, especially is this true in trying to properly care for the criminal insane. These unfortunate inmates should be housed in a separate building located here or at the State Hospital in Pueblo as might seem best to properly administer necessary psychiatric treatment and care. Under present conditions these inmates have insufficient mental classification and no psychiatric care.”[12] The prison hospital barely had the resources and facilities to care even for inmates without mental illness. During this time, prisoners with psychiatric disorders were essentially disregarded. Differential attention was given to these two classes of inmates, and care of the mentally ill fell short.

Up to this point, R. E. Holmes had been the only physician in the history of Territorial to advocate forcefully for the rights of the mentally ill. In his career at the prison he wrote countless reviews to the wardens and the Colorado legislature pleading for the means to find a place to house and care for the criminally insane. After Holmes died in 1938, Dr. Kon Wyatt replaced him as prison physician. He reported that “[t]he lunatics form about ten per cent of the prison population. We believe an intensive and thorough treatment of these individuals is our biggest problem.”[13] Mental illness was still an extremely important issue at Territorial but it had never met with adequate funding or programmatic response.

CSP’s psychiatric department

Over the next forty years the prison built and developed its psychiatric department. In 1979, the suicide rate at Colorado State Penitentiary was sixteen times higher than the national average. Nothing was done to lower this shocking statistic; evidently the state’s correctional authorities were unconcerned. Dr. Frank Rundle, a psychiatrist at prisons elsewhere in the country such as Soldedad and Rikers, believed that the mental health treatment at Cañon City institutions was “a giant kind of behavioral conditioning–but it’s all backward.”[14] Rundle concluded that the treatment encouraged negative responses in inmates rather than positive behavioral or perceptual adjustments. When seeking mental health treatment, inmates endured a “humiliating kind of experience.”[15] The prison psychologist George Levy was “explosive and violent” when discussing areas of mental health, and also had trouble dealing with psychotic inmates. Levy’s assistant, Larry Embry, found himself unable to visit inmates housed in the worst cell house at the maximum security unit due to the “psychological and emotional drain on him.”[16] Neither Levy nor Embry had had special training in working with the criminally insane before working at Territorial. Their work was further undercut by poor record-keeping and disorganized procedures for administering medications.[17] Even when the inmates finally received ostensibly medically informed treatment, it was performed by unqualified and incompetent individuals with little to no knowledge or expertise on working with the criminally insane.

In 1980, George Levy retired from his work at the prison at the request of Warden Henry Tinsley. During his twenty-three years of work at the prison, Levy had witnessed a change in the focus of treatment. He noted that “a confusion and lack of distinction between severe neurosis and social deviants led the court to decide that if you committed a crime you are sick and everyone had a right to treatment for that, but not all people are treatable.”[18] Those in power in the criminal justice system had begun to believe that inmates suffered from treatable illness rather than frank incompatibility with society, but the prison’s chief psychiatric officer was ambivalent about a new understanding of the role of mental illness in crime and evidently incapable of providing treatment according to the new paradigm.

Levy had seen his job as the psychologist at Colorado State Penitentiary was to serve the people of Colorado rather than the prisoners. His counseling emphasized the reality that the patient was in prison and that the patient should adjust to that reality. Levy stated, “it’s curious, though, that before rights, privileges and that stuff, we had less discipline problems, less neurotic breakdowns, less violence.”[19] He evidently believed that historical behavior management— procedures before mentally ill prisoners were treated like actual human beings with treatable diseases—were essentially better for the prison than subsequent, purportedly progressive methods because inmates handled under prior confinement paradigms had caused fewer problems. Levy repeatedly met with criticism from corrections staff for his language and usage, “I wrote reports pungently, caustically and sometimes amusingly for the benefit of people unsophisticated with psychology,” he later stated. While he was working at CSP, Levy received a letter of censure from every head of corrections, yet the state continued to allow him to care for the most vulnerable in the prison system.[20]

Deinstitutionalization

In 1981, Ronald Reagan was inaugurated president of the United States. For the next eight years, mental health took a back seat to executive pressure toward longer sentences and general “toughness” on crime. Mental health budgets were cut and grants for development of mental health policy blocked. The United State’s Medicaid, Supplemental Security Income and Section 8 housing funds failed to meet the necessities of the mentally ill.[21] Deinstitutionalization, the process of replacing long-term use of psychiatric facilities with community-based services, was systematically engraved into America’s policy and legislation. The purpose of this tremendous policy shift was to downsize the population of mental institutions and to reduce dependency, helplessness, and other damaging behaviors.[22] Despite these positive goals, however, deinstitutionalization merely replaced the overcrowding in mental asylums with other grave problems. A majority of the patients were released from the asylums, but many of them found their way into the criminal justice system because of untreated symptoms.

In 1989, the plans for constructing a new prison clinic to respond to the pressures of deinstitutionalization of mental patients were under development in Colorado. The legislature’s Joint Budget Committee toured the site for the proposed prison unit at Colorado State Hospital.[23] This proposed treatment center for mentally ill prisoners was the top priority on the list of the prison system’s capital construction needs. Kip Kautzky, director of the Colorado Department of Corrections at the time, stated that the remainder of an eighteen million-dollar renovation was spent on the 250-bed treatment center. A psychologist, social worker, drug-and-alcohol abuse counselor and a part-time psychiatrist were appointed to work at this center, developing treatment plans for inmates with different illnesses.[24] Successful construction of this center was Colorado State Penitentiary’s first real step to the legitimate treatment of mentally ill prisoners. The prison focused on hiring experienced professionals to work in the center, which would provide genuine medical care for the mentally ill.

In 1999 a committee and task force were created to investigate the needs of mentally ill inmates in Colorado prisons.[25] The purpose of the committee, comprised of nineteen experts in criminal justice and mental health, was to propose legislative and non-legislative solutions concerning diagnosis, treatment, and sentencing laws for mentally ill offenders as well as relevant training for criminal justice professionals. The task force would also study the possibility of creating mental health courts for minor offenders, conduct a comprehensive review of criminal-insanity law, and research the potential advantages of a “guilty but mentally ill” verdict.[26] The committee concluded that the criminal justice system was strained by a lack of resources, trained personnel, and space to house the mentally ill.[27] Although there was some treatment of the criminally insane, the criminal justice system still had only weak means to deal effectively with them.

The 1999 task force and committee proposed three bills to the state legislature. The first was to develop a standardized process for criminal justice and mental health agencies to detect mental illness in both adult and youth offenders. The second bill would allow needy inmates diagnosed with chronic mental illness to apply for state financial aid ninety days before their release from prison, preserving some limited financial stability for them once they were freed. The final bill would create community-based experimental treatment and management services including psychiatric treatment and medication, supervision and crisis intervention, and employment assistance for both adult and juvenile offenders.[28] The passage of this legislation was a major step toward reform of Colorado’s approach to the nexus of mental illness and mass incarceration.

Measures framed in 1999 to remediate the situation of mentally ill offenders still function today. More recent proposals to the legislature have included the development of a process to determine the competency of juveniles, the creation of health benefit plans that cover mental health services and services mandated by court, the creation of a Competency Evaluation Advisory Board, and the amendment of zoning laws to build transitional housing facilities. Some successful resulting programs have been intensive treatment programs, transition strategies programs, and the alternative sentencing method.[29] These programs were created with the intention of helping mentally ill offenders both inside and outside of prison. The intensive treatment programs are residential: they combine treatment for mental health and substance abuse. One example is Haven, a program run by the University of Colorado Denver School of Medicine, as an alternative to incarceration for women with serious substance abuse problems and co-occurring disorders. The John Eachon Re-entry Program, a transition strategy program, helps former inmates reenter their communities. It reduces the rate of recidivism and provides access to community-based therapy, medications, and collaborative case management. Graduates from this program receive employment opportunities, independent housing and the ability to return to school. The Alternative Sentencing Methods Program engages non-violent offenders to provide alternatives to incarceration. Again, this program reduces the rate of recidivism and allows those with mental illness access to the services that they need.[30] The Alternative Sentencing Methods Program and like programs support mentally ill prisoners once they are freed so they do not become a part of a cycle of returning to prison.

The current situation

Despite such efforts to ameliorate the condition of mentally ill Coloradans in the corrections system, the number of people with a mental illness in prison is absurdly high. Further, the number of mentally ill inmates in solitary confinement is appalling. In 2013 in the state of Colorado it was reported that, “prisoners with moderate to severe mental illness now make up the majority of those in solitary.”[31] Recently, legislation was passed that an inmate with a “severe” mental illness could not be allocated to solitary confinement.[32] The connection between mental illness and “administrative segregation,” as solitary confinement is officially labeled, raises many questions. What is the definition of a “serious” mental illness? Where is the line between a “moderate” and a “serious” mental illness, and who can determine this? Following the passage of this legislation, the American Civil Liberties Union issued a statement indicating that, “We remain concerned that the definition of major mental illness adopted by CDOC is too narrow and that there are still prisoners in administrative segregation who are seriously mentally ill.”[33] Although limitation of solitary confinement is itself progressive, it is sometimes used instrumentally. Prisoners who once were diagnosed with a serious mental illness have been reevaluated and diagnosed with moderate mental illnesses, so that they remain in solitary confinement. This form of isolating the mentally ill is disturbingly analogous to their segregation from the rest of the prison in the 1930’s.

The overall history of mental illness in Colorado prisons is tragic, yielding few records of treatment, therapy or use of medication. For several decades the focus of the Colorado State Penitentiary was to quarantine the mentally ill from the general prison population. After CSP accomplished this goal, the prison began to focus on the medicalized treatment of mentally ill people, it continued to find new ways to segregate the criminally insane from the rest of the prison community to their disadvantage in terms of care and rehabilitation. The prison even went so far as to separate the mentally ill from each other, placing them in solitary confinement. Recently there have been changes in both the treatment, but more than a century of neglect after the initial decision to incarcerate mentally ill has taken a heavy toll on Coloradoans doubly excluded from society by illness and criminal activity. The history of mental illness in prisons is a chronicle of abandonment, segregation, and minimal treatment. The future need not mirror the past. Steps are being taken to improve the lives and maintain the constitutional rights of mentally ill offenders. Recent media attention and activism by human rights organizations have heightened awareness of their plight, bringing hope for improvement in the lives of mentally ill offenders and better protection of their constitutional rights.

[21] PBS, “Deinstitutionalization: A Psychiatric ‘Titanic,’” 2005, accessed November 10, 2015, http://www.pbs.org. ison cycle. n in the 1930’t. isntal Ilness in Prisons and Jails: Ame a part of the continuous prison cycle. n in the 1930’t. is